HomeMy WebLinkAboutSeptic Pumping Slip - 82 RALEIGH TAVERN LANE 7/19/2018 Commonwealth „
RECEIVED
City[Town of19 2018
n.
Form"IF
i ua��� i�l i w ��N S A E1 .I.
DEP has provided this for M for uswby local Boards 6f Health. Other forms may ba bled,but the
information,roust be substantially the same as that provided here. Before using.this form.,check with your
local Board of Health to determine the form they use.The System.pumping Record must be submitted to
the local Board of Health or other approving authority.
A. cIliInform' sition
1. System Locatio , effl 1 fro: t of hro �� eft/dight rear of house, Left/right side of house, Left
Right side of buil Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown state Zip Code
2. System Owner:
Nome"
Address(if different from location)
Citylrown ` state Zip Code
'telephone Plumber '?
i
i
PuMpIng .
qcord `
1. Date of Pumping Date 2 QU ntity Pumped: — --` --r
Gallons
3. Type-of system: El Cesspool(s) Septic Tank El Tight Tank ,.
Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? ® Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Plumber
Bateson Enterprises Inc
Company
?. Lo tion_wbere contents were disposed:
S: Lowell Waste Water
Sign a Wale Cate
tMrm4.doo•08/03 System Pumping Record.Page 9 of 1